CurrentCignaPolicy N/A

Ophthalmic -Glaucoma -Carbonic Anhydrase Inhibitors Step Therapy Policy

Step therapy policy requiring trial of a Step 1 product (generic dorzolamide 2% ophthalmic solution) prior to coverage of the Step 2 product Trusopt (dorzolamide 2% ophthalmic solution - Merck). Applies to Cigna-administered health benefit plans; approvals provided for 1 year.

Policy Summary

PayerCigna

PolicyOphthalmic -Glaucoma -Carbonic Anhydrase Inhibitors Step Therapy Policy

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review DateOct 22, 2025

Key ActionPrior authorization required for Trusopt (Step 2) when a Step 1 product has not been tried; coverage approved if patient has tried one Step 1 drug. Approvals are valid for 1 year.

SourceLink

POLICY UPDATE CHANGES

Annual revisions noted with 'No criteria changes' for review dates 10/04/2023, 10/23/2024, and 10/22/2025.

1Required prior Step 1 agents

1 yrApproval duration

Coverage Summary

Scope: Step therapy policy requiring trial of a Step 1 product (generic dorzolamide 2% ophthalmic solution) prior to coverage of the Step 2 product Trusopt (dorzolamide 2% ophthalmic solution - Merck). Applies to Cigna-administered health benefit plans. Status: CURRENT. Subject: Ophthalmic Carbonic Anhydrase Inhibitors Step Therapy (dorzolamide/Trusopt). Coverage stance: covered_with_criteria. Effective/Last/Next review dates: Last review: 2024-10-23; Next review: 2025-10-22.

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Initial / Step Therapy Criteria

Step Therapy Criteria

Covered when ALL of the following are met:

Patient has tried one Step 1 drug (generic dorzolamide 2% ophthalmic solution).
If the patient has tried one Step 1 drug, approve a Step 2 Product.
Approvals are provided for 1 year in duration.

Unproven / Exclusions

No separate exclusions are listed. Operational limitations: approvals are provided for 1 year in duration. The policy explicitly encourages use of a Step 1 product prior to a Step 2 product and requires that if the patient has tried one Step 1 drug, a Step 2 product may be approved.

Applicable Codes

Drugs referencedNDC

generic dorzolamide 2% ophthalmic solution	Step 1 product (generic formulation)
Trusopt	Trusopt (dorzolamide 2% ophthalmic solution - Merck), Step 2 product

Provider Actions

Prior Authorization

Step therapy prior authorization requirement

Prior authorization required for Trusopt (Step 2) when a Step 1 product has not been tried; coverage approved if patient has tried one Step 1 drug. Approvals are valid for 1 year.

Affected products: Trusopt (Step 2) and generic dorzolamide 2% (Step 1)

Clinical Evidence & References

Evidence includes: Prescribing information: Dorzolamide 2% ophthalmic solution prescribing information, Bausch & Lomb; December 2022. No trial metric cards are provided in this policy.

Background

Dorzolamide 2% ophthalmic solution is indicated for treatment of elevated intraocular pressure in patients with ocular hypertension or open-angle glaucoma. The policy encourages use of a Step 1 product prior to Step 2. Definitions: Step 1 Product: generic dorzolamide 2% ophthalmic solution. Step 2 Product: Trusopt (dorzolamide 2% ophthalmic solution - Merck), which requires prior trial of a Step 1 product.

Revision History

10/04/2023annual_revision

Annual revisions noted with "No criteria changes". No clinical policy statement changes in the listed annual revisions.

10/23/2024annual_revisionLatest

Annual revisions noted with "No criteria changes". No clinical policy statement changes in the listed annual revisions.

10/22/2025annual_revision

Annual revisions noted with "No criteria changes". No clinical policy statement changes in the listed annual revisions.

Policy Summary

PayerCigna

PolicyOphthalmic -Glaucoma -Carbonic Anhydrase Inhibitors Step Therapy Policy

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review DateOct 22, 2025

Key ActionPrior authorization required for Trusopt (Step 2) when a Step 1 product has not been tried; coverage approved if patient has tried one Step 1 drug. Approvals are valid for 1 year.

SourceLink

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